Abnormal labor and delivery

Last updated: October 12, 2022

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Labor and delivery can be complicated by multiple factors: prolonged stages of labor can lead to active-phase labor arrest, obstructed labor can occur due to mechanical reasons (e.g., fetal malpresentation), abnormal rupture of membranes can increase the risk of chorioamnionitis and neonatal sepsis, and umbilical cord complications can increase the risk of birth asphyxia and stillbirth. Management of these complications is typically tailored to the individual and can include induction of labor, assisted delivery, special obstetrical maneuvers, antibiotics, intrauterine resuscitation measures, and emergency C-section.

See also “Normal labor and delivery,” “Preterm labor,” “Postpartum hemorrhage,” “Chorioamnionitis,” and “Birth traumas.”

Fetal malpresentation and fetal malposition are associated with increased perinatal risks and may require assisted delivery or C-section to prevent maternal and fetal complications (See “Obstructed labor”).

Fetal malpresentation

Fetal malposition

Etiology

  • Abnormalities of the 3 P's of labor
    • Pelvis: size and shape of the maternal pelvis (e.g., small bony pelvis)
    • Passenger: size and position of the infant (e.g., fetal macrosomia or abnormal orientation)
    • Power: strength and frequency of contractions (e.g., dysfunctional contractions )

Abnormal labor stages

Overview
Stage Characteristics Duration Management
Nulliparous patients Multiparous patients
First stage of labor Prolonged latent phase
  • > 20 hours
  • > 14 hours
  • Rest, hydration, and adequate analgesia
  • Oxytocin may be considered in well-rested mothers if the previous measures have been implemented.
  • Other: amniotomy, cervical ripening
Prolonged active phase
Arrested active phase
  • ≥ 6 cm cervical dilation with ruptured membranes and no cervical change after one of the following:
    • ≥ 4 hours of adequate contractions (≥ 200 Montevideo units)
    • > 6 hours of inadequate contractions
  • Usually due to abnormalities of the 3 P's of labor
Prolonged second stage of labor
  • > 3 hours (> 4 hours in patients who received an epidural)
  • > 2 hour (> 3 hours in patients who received an epidural)
  • Augmentation with oxytocin if uterine contractions are inadequate and progress is > 1 cm after 60–90 minutes of pushing
  • Trial of forceps or vacuum delivery if the fetal head is engaged and maternal contractions are adequate
  • Cesarean delivery if the fetal head is not engaged
Prolonged third stage of labor [1]

Complications of a prolonged second stage are postpartum hemorrhage and a poor neonatal outcome.

If the placenta is incomplete or if an accessory placenta is suspected, manual palpation should be performed and any remaining tissue should be removed by curettage.

Definition [2]

  • Arrest of vaginal delivery because of a mechanical obstruction (see “Arrested active phase” for comparison)

Predisposing factors

Clinical features

Management [2]

Complications

Neonatal [6][7]

Maternal [8]

Shoulder dystocia maneuvers
McRoberts maneuver
  • The patient should stop bearing down and lie supine with the buttocks on the edge of the bed.
  • Abduct, externally rotate, and hyperflex the maternal hips (with the maternal legs pulled towards the head).
Internal maneuvers Rubin maneuver*
Woods maneuver*
Delivery of posterior arm
Gaskin maneuver (all fours position)
  • The patient moves into hands and knees position.
  • Rubin and Woods maneuvers can be repeated.
Fracture of fetal clavicle
  • The fetal clavicle is surgically separated (cleidoctomy) or manually bent with the hand.
Zavanelli maneuver
Symphysiotomy

* May be performed with the McRoberts maneuver and may require episiotomy.

Most cases of shoulder dystocia occur in the absence of identifiable risk factors.

Rupture of membranes (ROM) typically occurs spontaneously during the first stage of labor. The following are abnormal variants of ROM.

Premature rupture of membranes (PROM)

Preterm premature rupture of membranes (PPROM)

Prolonged rupture of membranes

Diagnosis

Management [11]

The management of PROM and PPROM depends on the gestational age and the presence of intraamniotic infection or nonreassuring fetal status.

Unstable patients

Stable patients

Tocolysis is contraindicated in advanced labor (cervical dilation > 4 cm), chorioamnionitis, nonreassuring fetal signs, abruptio placentae, or risk of cord prolapse.

Causes

Umbilical cord prolapse

There are 3 types:

Overt umbilical cord prolapse

Occult umbilical cord prolapse

Cord presentation

Nuchal cord [2]

  • Most often caused by activity/turning of the fetus
  • Single cord around the neck: observed in ∼ 20% births
  • Multiple cord loops around the neck: < 1% births

Knotting of the umbilical cord

  • Most often caused by activity/turning of the fetus
  • Cord knot: 1–2% births

Indications

Contraindications

Modified Bishop score

Modified Bishop score
Score
0 points 1 point 2 points 3 points
Cervical position Posterior Midline Anterior
Cervical consistency Firm Moderately firm Soft (ripe)
Cervical effacement Up to 30% 31–50% 51–80% > 80%
Cervical dilation closed or 0 cm 1–2 cm 3–4 cm > 5 cm
Fetal station - 3 cm - 2 cm - 1/0 cm + 1/+ 2 cm

Approach

Obstetric forceps delivery [2]

Vacuum extractor delivery [2]

A routine episiotomy is not recommended with assisted vaginal delivery because of the risk of poor healing and anal sphincter injury!

An advantage of assisted vaginal delivery is avoiding cesarean delivery.

Indications [14][15][16][17][18]

Management [19][20][21]

  • Consists of an incision of the perineum (usually in the midline) to enlarge the vaginal opening during delivery
  • No longer routinely recommended.
  • Can be considered if vaginal delivery needs to be expedited and maternal perineal tissue is thought to pose a signficant obstacle, e.g.:
  1. Dutta DC, Konar H. Textbook of Obstetrics. Jaypee Brothers Medical Publishers ; 2015
  2. Raducha JE, Cohen B, Blood T, Katarincic J. A Review of Brachial Plexus Birth Palsy: Injury and Rehabilitation.. Rhode Island medical journal (2013). 2017; 100 (11): p.17-21.
  3. Intrapartum Care: Care of Healthy Women and Their Babies During Childbirth - NICE Clinical Guidelines, No. 190. https://www.ncbi.nlm.nih.gov/books/NBK328270/#__NBK328270_dtls__. Updated: December 1, 2014. Accessed: October 23, 2017.
  4. Arulkumaran S, Regan L, Papageorghiou A, Farquharson D, Monga A. Oxford Desk Reference: Obstetrics and Gynaecology. Oxford University Press ; 2011
  5. Bailey RE. Intrapartum fetal monitoring. Am Fam Physician. 2009; 80 (12): p.1388-1396.
  6. Chang KSG. Family Medicine. Lippincott Williams & Wilkins ; 2007
  7. Kennedy BB, Ruth DJ, Martin EJ. Intrapartum Management Modules. Lippincott Williams & Wilkins ; 2009
  8. Maharaj D. Intrapartum Fetal Resuscitation: A Review. The Internet Journal of Gynecology and Obstetrics. 2007; 9 (2).
  9. Feinstein N, Torgersen KL, Atterbury J, Association of Women's Health, Obstetric, and Neonatal Nurses. Fetal Heart Monitoring, Principles and Practices. Kendall/Hunt ; 1993
  10. ACOG Practice Bulletin Number 106, July 2009 - Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles.
  11. Haumonte JB, Blanc J, Castel P, et al. Uncertain fetal head engagement: a prospective randomized controlled trial comparing digital exam with angle of progression. Am J Obstet Gynecol. 2022 . doi: 10.1016/j.ajog.2022.04.018 . | Open in Read by QxMD
  12. Oyinloye OI, Okoyomo AA. Longitudinal evaluation of foetal transverse lie using ultrasonography.. Afr J Reprod Health. 2010; 14 (1): p.129-33.
  13. Dudenhausen JW, Obladen M. Practical Obstetrics. Walter de Gruyter GmbH & Co KG ; 2014
  14. Van Beekhuizen HJ, Unkels R, Mmuni NS, Kaiser M. Complications of obstructed labour: pressure necrosis of neonatal scalp and vesicovaginal fistula. The Lancet. 2006; 368 (9542): p.1210. doi: 10.1016/s0140-6736(06)69477-4 . | Open in Read by QxMD
  15. Fantu S, Segni H, Alemseged F. Incidence, Causes and Outcome of Obstructed Labor in Jimma University Specialized Hospital. Ethiopian Journal of Health Sciences. 2011; 20 (3). doi: 10.4314/ejhs.v20i3.69443 . | Open in Read by QxMD
  16. Global burden of obstructed labour in the year 2000. https://www.who.int/healthinfo/statistics/bod_obstructedlabour.pdf. . Accessed: July 26, 2021.
  17. Weeks AD. The retained placenta. Afr Health Sci. 2001; 1 (1): p.36-41.
  18. Assefa NE, Berhe H, Girma F, et al. Risk factors of premature rupture of membranes in public hospitals at Mekele city, Tigray, a case control study. BMC Pregnancy Childbirth. 2018; 18 (1). doi: 10.1186/s12884-018-2016-6 . | Open in Read by QxMD
  19. American College of Obstetricians and Gynecologists. Prelabor Rupture of Membranes: ACOG Practice Bulletin, Number 217.. Obstet Gynecol. 2020; 135 (3): p.e80-e97. doi: 10.1097/AOG.0000000000003700 . | Open in Read by QxMD
  20. Mackeen AD, Seibel-Seamon J, Muhammad J, Baxter JK, Berghella V. Tocolytics for preterm premature rupture of membranes. Cochrane Database of Systematic Reviews. 2014 . doi: 10.1002/14651858.cd007062.pub3 . | Open in Read by QxMD
  21. Magnesium Sulfate Use in Obstetrics. https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Magnesium-Sulfate-Use-in-Obstetrics. Updated: January 1, 2016. Accessed: July 22, 2017.
  22. Kaplan. USMLE Step 2 CK Lecture Notes 2017: Obstetrics/Gynecology . Kaplan Medical ; 2016

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